Clinical Textbook of Addictive Disorders 3rd ed - R. Frances, S. Miller, A. Mack (Guilford, 2005) WW

116 III. SUBSTANCES OF ABUSEis sufficient to cause demonstrable decreases in lung function (see also U.S.Department of Health and Human Services, 1994a).After high school, there is a gradual transition to regular adult smokinglevels, and the relative influence of dependence on nicotine increases (Sachs,1986). For most, smoking rates will hover around one pack per day and remainquite stable for most of their adult lives. Others will progress to higher smokingrates, again revealing marked day-to-day stability in nicotine ingestion.Tobacco dependence shows many features of a chronic disease (Fiore et al.,2000). Although a minority of tobacco users achieves permanent abstinence inan initial quit attempt, the majority persists in tobacco use for many years andtypically cycle through multiple periods of relapse and remission. More than70% of the 50 million smokers in the United States in 2000 had made at leastone prior quit attempt, and approximately 46% try to quit each year (Fiore etal., 2000). About 2% per year succeed (U.S. Department of Health and HumanServices, 1989b), with most making a number of attempts before succeeding.Nearly half of all living adults who ever smoked have quit (U.S. Departmentof Health and Human Services, 1989b), and most did so “on their own”(Schachter, 1982).DIFFERENTIAL DIAGNOSISThe diagnosis of nicotine dependence is relatively straightforward, particularlyin adults. Most adults admit that they smoke cigarettes, and they typicallysmoke on a daily basis. For adolescents and teens, smoking may not occur on adaily basis. The physician should ask them if they ever smoked and how frequentlythey smoke. If they do not smoke, or smoke only on occasion, the physicianshould inquire about expectations for smoking in the future. Older teens,of course, are more likely to report that they smoke on a daily basis, althoughthe number of cigarettes smoked per day may be fewer than those smoked byadults.The clinician often wishes to determine the severity of tobacco dependence,because such information provides insight into how difficult it will be forthe smoker to quit and what kind of quitting strategy will be most effective.Fagerstrom (1978) developed a brief nicotine dependence questionnaire.Among the most discriminating questions are the following: “How soon afteryou wake up do you smoke your first cigarette?”, “How many cigarettes a day doyou smoke?”, and “Have you stopped smoking or tried to stop smoking in thepast?” (Kozlowski et al., 1989).Heavy smokers, those who smoke soon after waking, and those who havenever quit smoking in the past are least likely to quit smoking on their own orwith assistance (cf. Hymowitz et al., 1997). They are the smokers who are mostlikely to benefit from nicotine replacement therapy (NRT) and other pharma-